II. Epidemiology

  1. Major Depression Incidence has increased in the last decade
    1. 2005: Major Depression episode in last year occurred in 9%
    2. 2014: Major Depression episode in last year occurred in 11%
    3. 2016: Major Depression episode in last year occurred in 13%
      1. From 5% in 12 year olds to 17% in 17 year olds
  2. Gender predominance
    1. Boys are slightly more likely than girls to have Major Depression before age 12 years old
    2. Girls are up to twice as likely as boys to experience Major Depression after Puberty

III. Precautions

  1. Missed or incorrect diagnosis occurs in up to 70%
  2. Major Depression is treated in only 40% of cases that effect children and teens
    1. Despite 70% experiencing significant Impairment from their Major Depression
  3. Pitfalls in diagnosis
    1. See Major Depression Differential Diagnosis
    2. Atypical presentations: Headaches, Stomache pain
    3. Downplayed symptoms if parents are also depressed

IV. Risk factors

  1. Comorbid illness (e.g. Diabetes Mellitus, Asthma)
  2. Puberty-related hormonal changes (esp. early Puberty)
  3. Family History of Major Depression
  4. Medications: Accutane
  5. Tobacco Abuse or Marijuana use
  6. Attention Deficit Disorder
  7. High functioning Autism
  8. LGBTQ
  9. Obesity
  10. Emotional stressors or social factors
    1. Poor family functioning or parental rejection
    2. Relationship break-ups or loss of loved one
    3. Video game addiction
    4. Social Media problematic use
    5. Decreased parent and peer attachment
    6. Victim of Bullying, Violence, physical, sexual or emotional abuse (see Child Abuse)
    7. Inadequate Physical Activity
    8. Natural disasters

V. Screening

  1. See Depression Screening Tools
  2. USPTF, AAFP and AAP all recommend Major Depression screening in age 12-18 years
  3. Ages 7 to 17 years old
    1. Childrens Depression Inventory (CDI)
  4. Ages 8 to 12 years old
    1. Reynolds Child Depression Scale
  5. Ages 13 to 18 years old
    1. Reynolds Adolescent Depression Scale
  6. Ages 13 and older
    1. Obtain Patient Health Questionnaire-2 (PHQ-2) each year at routine visit
    2. Patient Health Questionnaire-9 (PHQ-9) or PHQ-A (modified for ages to 11 to 17 years old)
  7. Ages 14 and older
    1. Beck Depression Inventory for Primary Care

VI. Diagnosis

VII. Differential Diagnosis

  1. See Major Depression Differential Diagnosis
  2. Pediatric Bipolar Disorder
    1. Presents with irritability, sadness and Insomnia (euphoria is typically absent)
  3. Persistent Depressive Disorder (Dysthymia)
    1. Depressed mood for more days than no depressed mood for at least one year
  4. Disruptive mood dysregulation
    1. Persistently angry with temper outbursts
    2. Post-Traumatic Stress Disorder may present in similar fashion
  5. Other associated conditions
    1. Eating Disorder
    2. Conduct Disorder
    3. Anxiety Disorder (comorbid with Major Depression in up to 74% of cases)
    4. Behavioral disorders (comorbid with Major Depression in up to 47% of cases)

VIII. Management: Psychotherapy

  1. Cognitive behavior therapy (CBT, 12-24 sessions of behavioral activation techniques)
    1. Coping skill improvement
    2. Communication skill improvement
    3. Peer relationship improvement
    4. Problem solving techniques
    5. Negative thinking pattern resolution
    6. Emotional regulation
  2. Interpersonal therapy (IPT, limited to adolescents and older)
    1. Adaptation to relationship changes
    2. Personal role transitions
    3. Interpersonal relationship building
  3. Therapy Plan with Goal Examples
    1. Treat others with respect
    2. Eat family meals
    3. Maintain school work
    4. Spend time with peers in activities
  4. Safety Plan
    1. Limit access to lethal Suicide methods (e.g. firearms)
  5. References
    1. David-Ferdon (2008) J Clin Child Adolesc Psychol 37(1): 62-104 [PubMed]
    2. Weersing (2006) Child Adolesc Psychiatr Clin N Am 15(4): 939-57 [PubMed]

IX. Management: Medications

  1. Background
    1. Medications are best combined with psychotherapy
    2. Psychosocial underlying factors respond best to therapy
      1. Trauma
      2. Divorce or separation
      3. Relationship break-ups
      4. Academic pressures
  2. Indications
    1. Moderate to severe depression
    2. Current depression with a prior episode
      1. Especially if treated with Antidepressants with the last episode
    3. Family History of depression
      1. Especially if significant response to medications in that family member
    4. Mood refractory to non-medication measures
      1. Refractory to modifications in environmental stressors
      2. Refractory to psychotherapy
    5. References
      1. Ryan (2003) Int J Methods Psychiatr Res 12(1): 44-53 [PubMed]
  3. Protocol
    1. Initial clinic visit
      1. Medication started
      2. Education of parents and patient
        1. Risks and benefits (see below)
        2. Common adverse effects of SSRIs and the delay in benefit for at leats 3-4 weeks
        3. Do not abrupty stop the SSRI (risk of Antidepressant Withdrawal)
        4. Warning signs to immediately seek medical attention
          1. Worsening depression
          2. Unusual behavior
          3. Suicidality
    2. Frequent phone calls (or clinic visits) after starting medication
      1. Schedule
        1. Every week for 4 weeks, then
        2. Every 2 weeks for 4 weeks
      2. Assess interim history
        1. Assess mood
        2. Assess for Suicidality
        3. Assess for Agitation, Insomnia, impulsivity (associated with Suicidality)
      3. Assess medication adverse effects
        1. Gastrointestinal adverse effects
        2. Nervousness
        3. Headache
        4. Motor restlessness
    3. Follow-up clinic visits
      1. Schedule (in addition to phone follow-up above)
        1. One month after starting medication
        2. Three months after starting medication
      2. Assess interim history
        1. Assess mood, Suicidality and adverse effects as above
        2. Titrate medication dose to effect
    4. Medication course
      1. Treat for at least 6 months after depression remission
  4. Selective Serotonin Reuptake Inhibitors
    1. All Antidepressants have an FDA black box warning regarding Suicidality risk in children
      1. Number Needed to Treat with SSRI for benefit in 1 child: 10
      2. Number needed to harm with SSRI for Suicidality in 1 child: 112
        1. Risk of Suicidality in children on Antidepressants is 0.7% higher than Placebo
    2. Preferred SSRIs that are FDA approved
      1. Fluoxetine (Prozac)
        1. SSRI most consistently found effective in Childhood Depression and FDA approved
        2. Start at 10 mg and titrate at follow-up visit in 2 weeks
      2. Escitalopram (Lexapro)
        1. FDA approved for age 12 years and older
    3. Other SSRIs that are well tolerated and have some evidence of benefit
      1. Citalopram (Celexa)
      2. Sertraline (Zoloft)
  5. Other Antidepressants that are not recommended
    1. Paroxetine is NOT recommended in children due to increased Suicidality, adverse effects (per FDA)
    2. Tricyclic Antidepressants appear ineffective
    3. Venlafaxine has less evidence to support use, and may have increased risk of Suicidality
    4. No evidence supporting MAO Inhibitors
  6. References
    1. (2014) Presc Lett 21(1): 5

X. Management: Psychiatry referral indications

  1. Symptoms refractory to first-line medications despite titration of dose
  2. Children with depression under age 11 years old
  3. Chronic depression
  4. Comorbid Substance Abuse
  5. Suicidality (especially if a Suicide plan)
  6. Parental engagement lacking

XI. Complications

  1. Suicide
    1. See Suicide Screening
    2. See Ask Suicide-Screening Questions (ASQ Suicide Screening Test)
    3. Seriously considered in 20% of teens
    4. Attempted Suicide in 8% of teens
  2. Growth Delay or Developmental Delay
  3. Impaired learning
  4. Persistent depression into adulthood (2-4 fold risk)

XII. Resources

  1. Patient Information: APA Guide to Medications in Children and Adolescents
    1. http://parentsmedguide.org/
  2. Suicide Prevention Lifeline
    1. Phone: (800) 273-TALK
  3. Crisis Text Line
    1. Text "HOME" to 741741

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